Overview

Although its primary objective is to safeguard the public, the California Dental
Practice Act is an excellent resource for dental professionals to ensure compliance with
state law. The California Dental Practice Act is the body of laws in the California Business
and Professions Code and the California Code of Regulations governing dental professionals,
including dentists, oral and maxillofacial surgeons, orthodontists, dental assistants, and
dental hygienists. The Act is intended to serve as a legal guideline for both professionals
and the public regarding all aspects of dental practice.

Audience

This course is designed for all California dentists, dental hygienists, and dental assistants in all practice settings.

Accreditations & Approvals

NetCE is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 10/1/2015 to 9/30/2021. Provider ID 217994.
NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Special Approvals

Course Objective

The purpose of this course is to provide California dental professionals with a working knowledge of the contents of the California Dental Practice Act, ensuring that they practice legally and safely.

Learning Objectives

Upon completion of this course, you should be able to:

Define the scope of practice of dental professionals in California.

Describe the standards of licensure of and medication prescription by dental professionals in California.

Identify possible victims of violence or neglect and outline the appropriate response.

Faculty

William E. Frey, DDS, MS, FICD, graduated from the University of California School of Dentistry, San Francisco, California, in 1966. In 1975, he completed residency training in Periodontics and received a Master\'s degree from George Washington University. He has been a member of the American Dental Association for over thirty-five years, and is a member of the American Academy of Periodontology and a Fellow in the International College of Dentists (FICD).

Dr. Frey retired from the United States Army Dental Corps in 1989 after 22 years of service. Throughout the course of his professional career, he has continuously practiced dentistry, the first 7 years as a general dentist and the past more than 30 as a periodontist. His military experience included the command of a networked Dental Activity consisting of five dental clinics. In his last assignment, he was in charge of a 38-chair facility. Colonel Frey was selected by the Army to serve on two separate occasions as the Chair of the Periodontal Department in Army General Dentistry Residency Training Programs.

Dr. Frey currently maintains a practice limited to Periodontics in Jackson, California, and is the founder and president of Perio Plus, a practice management firm specializing in creating individually-designed hygiene and periodontal care programs for general dentists. He is also the creator of the Inspector Gum patient education series.

Faculty Disclosure

Contributing faculty, William E. Frey, DDS, MS, FICD,
has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist
healthcare professionals to raise their levels of expertise while fulfilling their
continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the
information and recommendations are accurate and compatible with the standards
generally accepted at the time of publication. The publisher disclaims any
liability, loss or damage incurred as a consequence, directly or indirectly, of
the use and application of any of the contents. Participants are cautioned about
the potential risk of using limited knowledge when integrating new techniques into
practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial
interests are prohibited from distributing or providing access to this activity to
learners.

Table of Contents

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#51291: The California Dental Practice Act

Review your Transcript to view and print your Certificate of Completion.
Your date of completion will be the date (Pacific Time) the course was electronically
submitted for credit, with no exceptions. Partial credit is not available.

INTRODUCTION

The California Dental Practice Act is the body of laws in the California Business and Professions Code (CBPC) and the California Code of Regulations (CCR) governing all dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, unlicensed dental assistants, registered dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice. As defined in Section 1016.(b)1 of the CCR, continuing education on the California Dental Practice Act is required and must include instruction on utilization, scope of practice, prescribing laws, violations, citations, fines, licensure, the identification of abuse, and mandatory abuse reporting [1]. Of course, the Act is a much larger volume, so much so that it is beyond the scope of this course to elucidate every section. The Dental Practice Act is not intended to replace professional oaths and codes of ethics but does define actions and omissions that may lead to legal action and revocation of a license to practice dentistry in the State of California.

The Dental Board of California (a division of the California Department of Consumer Affairs), which consists of eight practicing dentists, one registered dental hygienist, one registered dental assistant, and five public members, is responsible for licensure of qualified dental health professionals, enforcement of the California Dental Practice Act, and improving the education of consumers and licensees [19]. It is the Board's mission to protect the health and safety of dental care consumers.

In addition, the practice of dental hygiene is regulated by the Dental Hygiene Committee of California, the first of its kind in the United States [20].

DENTISTRY DEFINED: SCOPE OF PRACTICE

According to the American Dental Association, dentistry is defined as "the evaluation, diagnosis, prevention, and/or treatment (nonsurgical, surgical, or related procedures) of diseases, disorders, and/or conditions of the oral cavity, maxillofacial area, and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training, and experience, in accordance with the ethics of the profession and applicable law" [2]. The CBPC and the CCR provide specific information regarding utilization and scope of practice for dentists, unlicensed dental assistants, registered dental assistants, and registered dental hygienists, as evidenced in the following sections [1].

DENTISTS

CBPC Section 1625. Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malpositions of the human teeth, alveolar process, gums, jaws, or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation. Without limiting the foregoing, a person practices dentistry within the meaning of this chapter who does any one or more of the following [24]:

(a) By card, circular, pamphlet, newspaper, or in any other way advertises himself or
represents himself to be a dentist.

(b) Performs, or offers to perform, an operation or diagnosis of any kind, or treats
diseases or lesions of the human teeth, alveolar process, gums, jaws, or associated
structures, or corrects malposed positions thereof.

(c) In any way indicates that he will perform by himself or his agents or servants any
operation upon the human teeth, alveolar process, gums, jaws, or associated structures, or
in any way indicates that he will construct, alter, repair, or sell any bridge, crown,
denture or other prosthetic appliance or orthodontic appliance.

(d) Makes, or offers to make, an examination of, with the intent to perform or cause to be
performed any operation on the human teeth, alveolar process, gums, jaws, or associated
structures.

(e) Manages or conducts as manager, proprietor, conductor, lessor, or otherwise, a place
where dental operations are performed.

The Board requires that dentists ensure that each patient of record receives a copy of the Dental Materials Fact Sheet (provided by the Board) prior to the placement of his or her first dental restoration [25]. The Dental Materials Fact Sheet details the comparative risks and benefits of available dental restorative materials. The patient must sign an acknowledgment of receipt of the fact sheet, and a copy of the acknowledgment must be placed in the patient's record.

DENTAL ASSISTANTS (UNLICENSED)

Although unlicensed dental assistants are not Board approved,
their duties and actions are governed by the Act and they are required to complete
coursework in the Dental Practice Act, infection control, and basic life support. Failure to
follow the regulations set forth by California law can result in fines and/or imprisonment.
As defined in CBPC Section 1750.(a), "A dental assistant is an individual who, without a
license, may perform basic supportive dental procedures, as authorized by Section 1750.1 and
by regulations adopted by the board, under the supervision of a licensed dentist" [1]. Basic supportive dental procedures are
those procedures that have technically elementary characteristics, are completely
reversible, and are unlikely to precipitate potentially hazardous conditions for the patient
being treated. A licensed dentist is responsible for assuring unlicensed dental assistants'
competence and ensuring that they complete required coursework and maintain certification in
basic life support (if employed for longer than 120 days). Specific duties pertaining to
dental assistant practice can be found in CCR Section 1085. General information regarding
regulations pertaining to dental assistants is located in CBPC Sections 1740–1777; although
these sections are not discussed in this course, they should be periodically reviewed to
ensure self-compliance with the act. The CBPC may include additional duties for various
dental assistant professions.

CCR Section 1085. Dental Assistant Duties and Settings.

(a) Unless specifically so provided by regulation, a dental assistant may not perform the
following functions or any other activity which represents the practice of dentistry or
requires the knowledge, skill and training of a licensed dentist:

Diagnosis and treatment planning;

Surgical or cutting procedures on hard or soft tissue;

Fitting and adjusting of correctional and prosthodontic appliances;

Prescription of medicines;

Placement, condensation, carving or removal of permanent restorations, including final cementation procedures;

Taking of impressions for prosthodontic appliances, bridges or any other structures which may be worn in the mouth;

Administration of injectable and/or general anesthesia;

Oral prophylaxis procedures.

(b) A dental assistant may perform such basic supportive dental procedures as the
following under the general supervision of a licensed dentist:

Extra-oral duties or functions specified by the supervising dentist;

Operation of dental radiographic equipment for the purpose of oral radiography if the dental assistant has complied with the requirements of section 1656 of the Code;

Examine orthodontic appliances.

(c) A dental assistant may perform such basic supportive dental procedures as the
following under the direct supervision of a licensed dentist when done so pursuant to the
order,control and full professional responsibility of the supervising dentist. Such
procedures shall be checked and approved by the supervising dentist prior to dismissal of
the patient from the office of said dentist.

Take impressions for diagnostic and opposing models, bleaching trays, temporary crowns and bridges, and sports guards;

Apply non-aerosol and non-caustic topical agents;

Remove post-extraction and periodontal dressings;

Placement of elastic orthodontic separators;

Remove orthodontic separators;

Assist in the administration of nitrous oxide analgesia or sedation; however, a dental assistant shall not start the administration of the gases and shall not adjust the flow of the gases unless instructed to do so by the dentist who shall be present at the patient's chairside at the implementation of these instructions. This regulation shall not be construed to prevent any person from taking appropriate action in the event of a medical emergency.

Apply topical fluoride, after scaling and polishing by the supervising dentist or a registered dental hygienist;

Place and remove rubber dams;

Place, wedge and remove matrices;

Cure restorative or orthodontic materials in operative site with light-curing device.

For the purpose of this section, a supervising licensed dentist is defined as a dentist whose patient is receiving the services of a dental assistant in the treatment facility and is under the direct control of said licensed dentist [1]. Direct supervision is defined as supervision of dental procedures based on instructions given by a licensed dentist who must be physically present in the facility when the procedures are performed.

REGISTERED DENTAL ASSISTANTS

Registered dental assistants (RDAs) are Board-licensed professionals who may perform a greater range of duties than unlicensed dental assistants. Specific information pertaining to RDAs' scope of practice can be found in CCR Section 1086, and general information regarding regulations pertaining to RDAs is located in CBPC Sections 1740–1777, which should be reviewed periodically to ensure self-compliance with the act.

CCR Section 1086. RDA Duties and Settings.

(a) Unless specifically so provided by regulation, the prohibitions contained in section
1085 of these regulations apply to registered dental assistants.

(b) A registered dental assistant may perform all functions which may be performed by a
dental assistant.

(c) Under general supervision, a registered dental assistant may perform the following
duties:

Mouth-mirror inspection of the oral cavity, to include charting of obvious lesions, existing restorations and missing teeth;

Placement and removal of temporary sedative dressings.

(d) A registered dental assistant may perform the following procedures under the direct
supervision of a licensed dentist when done so pursuant to the order, control and full
professional responsibility of the supervising dentist. Such procedures shall be checked and
approved by the supervising dentist prior to dismissal of the patient from the office of
said dentist.

Obtain endodontic cultures;

Dry canals, previously opened by the supervising dentist, with absorbent points;

Test pulp vitality;

Place bases and liners on sound dentin;

Remove excess cement from supragingival surfaces of teeth with a hand instrument or floss;

Size stainless steel crowns, temporary crowns and bands;

Fabrication of temporary crowns intra-orally;

Temporary cementation and removal of temporary crowns and removal of orthodontic bands;

Placement of orthodontic separators;

Placement and ligation of arch wires;

Placement of post-extraction and periodontal dressings;

Apply bleaching agents;

Activate bleaching agents with non-laser light-curing device;

Take bite registrations for diagnostic models for case study only;

Coronal polishing (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof). The processing times for coronal polishing course approval are set forth in section 1069.

This procedure shall not be intended or interpreted as a complete oral prophylaxis (a procedure which can be performed only by a licensed dentist or registered dental hygienist). A licensed dentist or registered dental hygienist shall determine that the teeth to be polished are free of calculus or other extraneous material prior to coronal polishing.

Removal of excess cement from coronal surfaces of teeth under orthodontic treatment by means of an ultrasonic scaler. (Evidence of satisfactory completion of a board-approved course of instruction or equivalent instruction in an approved RDA program in this function must be submitted to the board prior to any performance thereof.) The processing times for ultrasonic scaler course approval are set forth in section 1069.

(e) Settings. Registered dental assistants may undertake the duties authorized by this
section in a treatment facility under the jurisdiction and control of the supervising
licensed dentist, or in an equivalent facility approved by the board.

Registered Dental Assistants in Extended Functions

Registered dental assistants in extended functions (RDAEFs) are Board-licensed dental professionals who have a greater breadth of permitted duties than RDAs. Specifics regarding these allowed duties can be found in CCR Section 1087.

CCR Section 1087. RDAEF Duties and Settings.

(a) Unless specifically so provided by regulation, the prohibitions contained in Section
1085 apply to RDAEFs.

(b) An RDAEF may perform all duties assigned to dental assistants and registered dental
assistants.

(c) An RDAEF may perform the procedures set forth below under the direct supervision of
a licensed dentist when done so pursuant to the order, control and full professional
responsibility of the supervising dentist. Such procedures shall be checked and approved
by the supervising dentist prior to dismissal of the patient from the office of said
dentist.

Cord retraction of gingivae for impression procedures;

Take impressions for cast restorations;

Take impressions for space maintainers, orthodontic appliances, and occlusal guards;

(d) Settings. Registered dental assistants in extended functions may undertake the
duties authorized by this section in a treatment facility under the jurisdiction and
control of the supervising licensed dentist, or in an equivalent facility approved by the
board.

In addition to the duties outlined in CCR section 1087, section 1753.5 of the CBPC states that RDAEFs may conduct preliminary evaluation of the patient's oral health, including, but not limited to, charting, intraoral and extra-oral evaluation of soft tissue, classifying occlusion, and myofunctional evaluation, and perform oral health assessments in school-based, community health project settings under the direction of a dentist, registered dental hygienist, or registered dental hygienist in alternative practice [1]. RDAEFs may hold an orthodontic assistant permit, a dental sedation assistant permit, or both.

DENTAL HYGIENISTS

Registered dental hygienists (RDHs), registered dental hygienists in extended functions (RDHEFs), and registered dental hygienists in alternative practice (RDHAPs) are Board-licensed occupations administered by the Dental Hygiene Committee of California, and the California Dental Practice Act contains the main body of laws and regulations that govern their practice.

The Dental Hygiene Committee of California was created by the Board and consists of nine governor-appointed positions: four public members, four dental hygienists, and one practicing dentist [20]. Responsibilities of the Dental Hygiene Committee include adopting regulations; issuing, reviewing, and revoking licenses; developing and administering examinations; determining fees; and updating continuing education requirements for all dental hygiene licensure categories. The Act contains specific information regarding the permitted duties and settings of RDH practice (CCR Section 1088), RDHEF practice (CCR Section 1089), and RDHAP practice (CCR Section 1090). Additional laws and regulations pertaining specifically to dental hygiene practice are located in CBPC Sections 1900–1966.6. These sections should be periodically reviewed to ensure self-compliance with the Act.

Registered Dental Hygienists

CCR Section 1088. RDH Duties and Settings.

(a) Unless specifically so provided by regulation, the
prohibition contained in Section 1085(a), subsections (1) through (8) of these regulations
shall apply to duties performed by a registered dental hygienist.

(b) A registered dental hygienist may perform all duties
assigned to dental assistants and registered dental assistants, under the supervision of a
licensed dentist as specified in these regulations.

(c) Under general supervision, a registered dental
hygienist may perform the following duties in addition to those provided by Section
1760(b) of the Code:

The following direct supervision duties of dental assistants and registered dental
assistants:

(B) Registered Dental Assistant

Test pulp vitality;

Removing excess cement from supragingival surfaces of teeth;

Sizing stainless steel crowns, temporary crowns and bands;

Temporary cementation and removal of temporary crowns and removal of orthodontic
bands;

Placing post-extraction and periodontal dressings.

(d) A registered dental hygienist may perform the
procedures set forth below under the direct supervision of a licensed dentist when done so
pursuant to the order, control and full professional responsibility of the supervising
dentist. Such procedures shall be checked and approved by the supervising dentist prior to
dismissal of the patient from the office of said dentist.

Placement of antimicrobial or antibiotic medicaments which do not later have to be
removed;

All duties so assigned to a dental assistant or a registered dental assistant,
unless otherwise indicated;

Periodontal soft tissue curettage (Evidence of satisfactory completion of a
board-approved course of instruction in this function must be submitted to the board
prior to any performance thereof);

Administration of local anesthetic agents, infiltration and conductive, limited to
the oral cavity (Evidence of satisfactory completion of a board-approved course of
instruction in this function must be submitted to the board prior to any performance
thereof);

Administration of nitrous oxide and oxygen when used as an analgesic, utilizing
fail-safe type machines containing no other general anesthetic agents. (Evidence of
satisfactory completion of a board-approved course of instruction in this function
must be submitted to the board prior to any performance thereof.)

(e) A registered dental hygienist may undertake the duties
authorized by this section in the following settings, provided the appropriate supervision
requirements are met:

The treatment facility of a licensed dentist;

Licensed health facilities as defined in Section 1250 of the Health and Safety
Code,

Licensed clinics as defined in Section 1203 of the Health and Safety Code,

Licensed community care facilities as defined in Section 1502 of the Health and
Safety Code,

Schools of any grade level whether public or private,

Public institutions, including but not limited to federal, state and local penal
and correctional facilities.

Mobile units operated by a public or governmental agency or a nonprofit and
charitable organization approved by the board; provided, however, that the mobile unit
meets the statutory and regulatory requirements for mobile units,

Home of a non-ambulatory patient, provided there is a written note from a
physician or registered nurse stating that the patient is unable to visit a dental
office.

Health fairs or similar non-profit community activities. Each such fair or
activity shall be approved by the board.

(c) An RDHEF may perform the procedures set forth below under the direct supervision of
a licensed dentist when done so pursuant to the order, control and full professional
responsibility of the supervising dentist. Such procedures shall be checked and approved
by the supervising dentist prior to dismissal of the patient from the office of said
dentist.

Cord retraction of gingivae for impression procedures;

Take impressions for cast restorations;

Take impressions for space maintainers, orthodontic appliances and guards;

Prepare enamel by etching for bonding;

Formulate indirect patterns for endodontic post and core castings;

Fit trial endodontic filling points;

Apply etchant for bonding restorative materials.

(d) Settings. Registered dental hygienists in extended functions may undertake the
duties authorized by this section in a treatment facility under the jurisdiction and
control of the supervising licensed dentist, or an equivalent facility approved by the
Board.

Registered Dental Hygienists in Alternative Practice

CCR Section 1090. RDHAP Duties and Settings.

(a) Unless specifically so provided by regulation, an RDHAP may not perform the
following functions or any activity which represents the practice of dentistry or requires
knowledge, skill and training of a licensed dentist:

Diagnosing and treatment planning;

Surgical or cutting procedures on hard or soft tissue;

Fitting and adjusting of correctional and prosthodontic appliances;

Prescribing medication;

Placing, condensing, carving or removal of permanent restorations, including final cementation procedures;

Taking of impressions for prosthodontic appliances, bridges, or any other devices which may be worn in the mouth;

Administering local or general anesthesia, oral or parental conscious sedation.

(b) Under the supervision of a licensed dentist, an RDHAP may perform the duties
assigned to registered dental hygienists by Section 1088, under the same levels of
supervision and in the same settings as specified in that section, in addition to those
duties permitted by Section 1768(b)(3).

(c) Independently and without the supervision of a licensed dentist, an RDHAP may, upon
the prescription of a dentist or a physician and surgeon licensed in California, perform
the duties assigned to a registered dental hygienist by Section 1088(c).

All prescriptions shall contain the following information:

The pre-printed name, address, license number, and signature of the prescribing dentist or physician and surgeon.

The name, address and phone number of the patient.

The date the services are prescribed and the expiration date of the prescription. The prescription shall be for dental hygiene services and, if necessary, include special instructions for the care of that patient.

Prior to the establishment of an independent practice, an RDHAP shall provide to the board documentation of an existing relationship with at least one dentist for referral, consultation, and emergency services [1].

LICENSURE

All individuals practicing dentistry in California, with the
exception of unlicensed dental assistants, must hold a current, valid license issued by the
Board; California does not grant reciprocity with other states or nations. The Act requires
that dental professionals meet certain education requirements, submit the correct applications
and fees, pass the appropriate examinations, and submit a set of fingerprints. Fingerprinting
is also required for license renewal if not previously conducted by the Dental
Board/California Department of Justice (DOJ) or if records no longer exist [21]. Fingerprinting must be conducted using the
DOJ Live Scan system; fingerprint records from other institutions (e.g., Department of Motor
Vehicles) are not suitable. The fingerprints will be used to conduct a criminal history record
check and a state and federal level criminal offender record information search.

Issuance, review, and revocation of RDH/RDHEF/RDHAP licenses and the development and administration of license examinations for these auxiliaries are handled by the Dental Hygiene Committee of California. All other licensure, including that for RDAs/RDAEFs, is handled by the Dental Board (despite the existence of the Dental Assisting Council, whose purpose is to consider matters related to dental assisting practice and make recommendations to the board). Complaints, investigations, and enforcement are handled by either the Dental Hygiene Committee or the Dental Board, according to profession, but the governing regulations and laws set forth in the California Dental Practice Act pertain to all dental professionals. Information about application for licensure to practice as a dentist or dental auxiliary can be found in CCR Section 1028 and CCR Sections 1076–1079.3, respectively. Specific information about the licensure application requirements and process for dentists and dental assistants can be found at http://www.dbc.ca.gov/applicants and for hygienists at http://www.dhcc.ca.gov/applicants.

Effective July 2012, application for licensure may be denied based on delinquent state tax payments [1]. Similarly, current licenses/certifications/registrations may be revoked for failure to pay taxes.

LICENSE RENEWAL

Licenses for all dental profession must be renewed every two years before the last day of the professional's birth month. Practicing without renewing after this date is considered practicing without a license [1]. It is required that dentists have completed 50 hours of continuing education and dental auxiliaries (excluding RDHAPs) have completed 25 hours of continuing education (maximum of 25 hours and 12.5 hours of home study, respectively) upon renewal submission. The continuing education requirement is 35 hours for RDHAPs. Coursework regarding the Dental Practice Act, infection control, and basic life support is mandatory every two years for all licensees. To receive credit, all courses must be from board-approved providers. In addition, the Board has identified topics that may only constitute a portion of the full continuing education requirement or that are not acceptable at all. A complete listing of allowable and non-allowable courses is available on the Board website.

ACTS LEADING TO SUSPENSION OF A LICENSE AND IN VIOLATION OF THE DENTAL PRACTICE ACT

Violations of the Act by Board licensees are grounds for suspension of a license/certification and are handled by the Board's Enforcement Program, which is composed of five sections: complaint intake, complaint analysis, inspection, investigation, and probation [22]. Complaints originate from many sources, including dental professionals, healthcare providers, insurance companies, law enforcement agencies, and patients. Complaint intake specialists route these to the appropriate section; for example, an allegation of an unsafe or unsanitary office condition is routed to the inspection section, whereby Board enforcement inspectors may be sent out and are authorized to issue citations and fines. In addition to Board enforcement action, other law enforcement or regulatory agencies are involved when indicated [1]. Dental professionals placed on probation status by the Board for violations of the Act are monitored by the Enforcement Program's probation section. The Board's Enforcement Unit may be contacted at (916) 274-6326. Violations of the Act by hygienists are handled by the Hygiene Committee's Complaint Unit, which operates in a similar manner and can be contacted at (866) 810-9899.

According to CCR Section 490.(b), conviction of crimes
committed by dental professionals outside of the workplace may also be grounds for Board
discipline and can impact licensure status if the crime is "substantially related to the
qualifications, functions, or duties of the business or profession for which the licensee's
license was issued" [1]. These vary
considerably on a case-by-case basis. Various lesser convictions, for example, driving under
the influence (DUI), illicit drug possession, and prescription drug diversion, may not
necessarily lead to license revocation provided the proper steps are taken toward
remediation (e.g., entering the Board diversion program, submitting to periodic drug
testing) [23]. In general, convictions for
assaults, sex crimes, multiple misdemeanors (e.g., second DUI/controlled substance charge),
and other egregious violations constitute a basis for denial or revocation of licenses or
certifications. In addition to violations outside the workplace, unprofessional conduct, in
its many forms, is grounds for Board Enforcement action. Acts and omissions that
characterize unprofessional conduct are covered extensively in CBPC Sections 1680, 1681, and
1682 and CCR Section 1018.05.

CBPC Section 1680. Unprofessional conduct by a person
licensed under this chapter is defined as, but is not limited to, any one of the
following:

(a) The obtaining of any fee by fraud or
misrepresentation.

(b) The employment directly or indirectly of any student or
suspended or unlicensed dentist to practice dentistry as defined in this chapter.

(c) The aiding or abetting of any unlicensed person to
practice dentistry.

(d) The aiding or abetting of a licensed person to practice
dentistry unlawfully.

(e) The committing of any act or acts of sexual abuse,
misconduct, or relations with a patient that are substantially related to the practice of
dentistry.

(f) The use of any false, assumed, or fictitious name, either
as an individual, firm, corporation, or otherwise, or any name other than the name under
which he or she is licensed to practice, in advertising or in any other manner indicating
that he or she is practicing or will practice dentistry, except that name as is specified in
a valid permit issued pursuant to Section 1701.5.

(g) The practice of accepting or receiving any commission or
the rebating in any form or manner of fees for professional services, radiograms,
prescriptions, or other services or articles supplied to patients.

(h) The making use by the licensee or any agent of the
licensee of any advertising statements of a character tending to deceive or mislead the
public.

(i) The advertising of either professional superiority or the
advertising of performance of professional services in a superior manner.

(l) The advertising to guarantee any dental service, or to
perform any dental operation painlessly.

(m) The violation of any of the provisions of law regulating
the procurement, dispensing, or administration of dangerous drugs, as defined in Chapter 9
(commencing with Section 4000) or controlled substances, as defined in Division 10
(commencing with Section 11000) of the Health and Safety Code.

(n) The violation of any of the provisions of this
division.

(o) The permitting of any person to operate dental
radiographic equipment who has not met the requirements of Section 1656.

(p) The clearly excessive prescribing or administering of
drugs or treatment, or the clearly excessive use of diagnostic procedures, or the clearly
excessive use of diagnostic or treatment facilities, as determined by the customary practice
and standards of the dental profession. Any person who violates this subdivision is guilty
of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100)
or more than six hundred dollars ($600), or by imprisonment for a term of not less than 60
days or more than 180 days, or by both a fine and imprisonment.

(q) The use of threats or harassment against any patient or
licensee for providing evidence in any possible or actual disciplinary action, or other
legal action; or the discharge of an employee primarily based on the employee's attempt to
comply with the provisions of this chapter or to aid in the compliance.

(r) Suspension or revocation of a license issued, or
discipline imposed, by another state or territory on grounds that would be the basis of
discipline in this state.

(s) The alteration of a patient's record with intent to
deceive.

(t) Unsanitary or unsafe office conditions, as determined by
the customary practice and standards of the dental profession.

(u) The abandonment of the patient by the licensee, without
written notice to the patient that treatment is to be discontinued and before the patient
has ample opportunity to secure the services of another dentist, registered dental
hygienist, registered dental hygienist in alternative practice, or registered dental
hygienist in extended functions and provided the health of the patient is not
jeopardized.

(v) The willful misrepresentation of facts relating to a
disciplinary action to the patients of a disciplined licensee.

(w) Use of fraud in the procurement of any license issued
pursuant to this chapter.

(x) Any action or conduct that would have warranted the
denial of the license.

(z) The failure to report to the board in writing within
seven days any of the following: (1) the death of his or her patient during the performance
of any dental or dental hygiene procedure; (2) the discovery of the death of a patient whose
death is related to a dental or dental hygiene procedure performed by him or her; or (3)
except for a scheduled hospitalization, the removal to a hospital or emergency center for
medical treatment for a period exceeding 24 hours of any patient to whom oral conscious
sedation, conscious sedation, or general anesthesia was administered, or any patient as a
result of dental or dental hygiene treatment. With the exception of patients to whom oral
conscious sedation, conscious sedation, or general anesthesia was administered, removal to a
hospital or emergency center that is the normal or expected treatment for the underlying
dental condition is not required to be reported. Upon receipt of a report pursuant to this
subdivision the board may conduct an inspection of the dental office if the board finds that
it is necessary. A dentist shall report to the board all deaths occurring in his or her
practice with a copy sent to the Dental Hygiene Committee of California if the death was the
result of treatment by a registered dental hygienist, registered dental hygienist in
alternative practice, or registered dental hygienist in extended functions. A registered
dental hygienist, registered dental hygienist in alternative practice, or registered dental
hygienist in extended functions shall report to the Dental Hygiene Committee of California
all deaths occurring as the result of dental hygiene treatment, and a copy of the
notification shall be sent to the board.

(aa) Participating in or operating any group advertising and
referral services that are in violation of Section 650.2.

(ab) The failure to use a fail-safe machine with an
appropriate exhaust system in the administration of nitrous oxide. The board shall, by
regulation, define what constitutes a fail-safe machine.

(ae) The utilization by a licensed dentist of any person to
perform the functions of any registered dental assistant, registered dental assistant in
extended functions, dental sedation assistant permitholder, orthodontic assistant
permitholder, registered dental hygienist, registered dental hygienist in alternative
practice, or registered dental hygienist in extended functions who, at the time of initial
employment, does not possess a current, valid license or permit to perform those
functions.

(af) The prescribing, dispensing, or furnishing of dangerous
drugs or devices, as defined in Section 4022, in violation of Section 2242.1.

Section 1681. In addition to other acts constituting unprofessional conduct within the
meaning of this chapter, it is unprofessional conduct for a person licensed under this
chapter to do any of the following:

(a) Obtain or possess in violation of law, or except as directed by a licensed physician
and surgeon, dentist, or podiatrist, administer to himself, any controlled substance, as
defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any
dangerous drug as defined in Article 8 (commencing with Section 4211) of Chapter 9.

(b) Use any controlled substance, as defined in Division 10 (commencing with Section
11000) of the Health and Safety Code, or any dangerous drug as defined in Article 8
(commencing with Section 4211) of Chapter 9, or alcoholic beverages or other intoxicating
substances, to an extent or in a manner dangerous or injurious to himself, to any person, or
the public to the extent that such use impairs his ability to conduct with safety to the
public the practice authorized by his license.

(c) The conviction of a charge of violating any federal statute or rules, or any statute
or rule of this state, regulating controlled substances, as defined in Division 10
(commencing with Section 11000) of the Health and Safety Code, or any dangerous drug, as
defined in Article 8 (commencing with Section 4211) of Chapter 9, or the conviction of more
than one misdemeanor, or any felony, involving the use or consumption of alcohol or drugs,
if the conviction is substantially related to the practice authorized by his license. The
record of conviction or certified copy thereof, certified by the clerk of the court or by
the judge in whose court the conviction is had, shall be conclusive evidence of a violation
of this section; a plea or verdict of guilty or a conviction following a plea of nolo contendere is deemed to be a conviction within the meaning
of this section; the board may order the license suspended or revoked, or may decline to
issue a license, when the time for appeal has elapsed or the judgment of conviction has been
affirmed on appeal, or when an order granting probation is made suspending imposition of
sentence, irrespective of a subsequent order under any provision of the Penal Code,
including, but not limited to, Section 1203.4 of the Penal Code, allowing such person to
withdraw his plea of guilty and to enter a plea of not guilty, or setting aside the verdict
of guilty, or dismissing the accusation, information or indictment.

Section 1682. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for:

(a) Any dentist performing dental procedures to have more than one patient undergoing
conscious sedation or general anesthesia on an outpatient basis at any given time unless
each patient is being continuously monitored on a one-to-one ratio while sedated by either
the dentist or another licensed health professional authorized by law to administer
conscious sedation or general anesthesia.

(b) Any dentist with patients recovering from conscious sedation or general anesthesia to
fail to have the patients closely monitored by licensed health professionals experienced in
the care and resuscitation of patients recovering from conscious sedation or general
anesthesia. If one licensed professional is responsible for the recovery care of more than
one patient at a time, all of the patients shall be physically in the same room to allow
continuous visual contact with all patients and the patient to recovery staff ratio should
not exceed three to one.

(c) Any dentist with patients who are undergoing conscious sedation to fail to have these
patients continuously monitored during the dental procedure with a pulse oximeter or similar
or superior monitoring equipment required by the board.

(d) Any dentist with patients who are undergoing conscious sedation to have dental office
personnel directly involved with the care of those patients who are not certified in basic
cardiac life support (e.g., CPR) and recertified biennially.

(e) Any dentist to fail to obtain the written informed consent of a patient prior to
administering general anesthesia or conscious sedation. In the case of a minor, the consent
shall be obtained from the child's parent or guardian.

Section 1683. (a) Every dentist, dental health professional, or other licensed health professional who performs a service on a patient in a dental office shall identify himself or herself in the patient record by signing his or her name, or an identification number and initials, next to the service performed and shall date those treatment entries in the record. Any person licensed under this chapter who owns, operates, or manages a dental office shall ensure compliance with this requirement.

Section 1684. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for a person licensed under this chapter to perform, or hold himself or herself out as able to perform, professional services beyond the scope of his or her license and field or fields of competence as established by his or her education, experience, training, or any combination thereof. This includes, but is not limited to, the use of any instrument or device in a manner that is not in accordance with the customary standards and practices of the dental profession. This section shall not apply to research conducted by accredited dental schools or colleges, or to research conducted pursuant to an investigational device exemption issued by the United States Food and Drug Administration.

1684.5. (a) In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for any dentist to perform or allow to be performed any treatment on a patient who is not a patient of record of that dentist. A dentist may, however, after conducting a preliminary oral examination, require or permit any dental auxiliary to perform procedures necessary for diagnostic purposes, provided that the procedures are permitted under the auxiliary's authorized scope of practice.

Additionally, a dentist may require or permit a dental auxiliary to perform all of the following duties prior to any examination of the patient by the dentist, provided that the duties are authorized for the particular classification of dental auxiliary pursuant to Article 7 (commencing with Section 1740):

Expose emergency radiographs upon direction of the dentist.

Perform extra-oral duties or functions specified by the dentist.

Perform mouth-mirror inspections of the oral cavity, to include charting of obvious lesions, malocclusions, existing restorations, and missing teeth.

(b) For purposes of this section, "patient of record" refers to a patient who has been
examined, has had a medical and dental history completed and evaluated, and has had oral
conditions diagnosed and a written plan developed by the licensed dentist.

(c) This section shall not apply to dentists providing examinations on a temporary basis
outside of a dental office in settings including, but not limited to, health fairs and
school screenings.

(d) This section shall not apply to fluoride mouth rinse or supplement programs
administered in a school or preschool setting.

Section 1685. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for a person licensed under this chapter to require, either directly or through an office policy, or knowingly permit the delivery of dental care that discourages necessary treatment or permits clearly excessive treatment, incompetent treatment, grossly negligent treatment, repeated negligent acts, or unnecessary treatment, as determined by the standard of practice in the community.

CCR Section 1018.05 Unprofessional Conduct Defined. In addition to those acts detailed in Business and Professions Code Sections 1670, 1680, 1681 and 1682, the following shall also constitute unprofessional conduct:

(a) Failure to provide records requested by the Board within 15 days of the date of
receipt of the request or within the time specified in the request, whichever is later,
unless the licensee is unable to provide the documents within this time period for good
cause. For the purposes of this section, "good cause" includes physical inability to access
the records in the time allowed due to illness or travel.

(b) Failure to report to the Board, within 30 days, any of the following:

The bringing of an indictment or information charging a felony against the licensee.

The conviction of the licensee, including any verdict of guilty, or pleas of guilty or no contest, of any felony or misdemeanor.

Any disciplinary action taken by another professional licensing entity or authority of this state or of another state or an agency of the federal government or the United States military.

For the purposes of this section, "conviction" means a plea or verdict of guilty or a conviction following a plea of nolo contendere or "no contest" and any conviction that has been set aside or deferred pursuant to Sections 1000 or 1203.4 of the Penal Code, including infractions, misdemeanors, and felonies. "Conviction" does not include traffic infractions with a fine of less than one thousand dollars ($1,000) unless the infraction involved alcohol or controlled substances.

VIOLATIONS AND PENALTIES

As discussed, various acts or omissions can be cause for revocation or suspension of a license. Violation of any section of the Dental Practice Act can also lead to civil and criminal prosecution, including [1]:

Section 1700. Any person, company, or association is guilty of a misdemeanor, and upon conviction thereof shall be punished by imprisonment in the county jail not less than 10 days nor more than one year, or by a fine of not less than one hundred dollars ($100) nor more than one thousand five hundred dollars ($1,500), or by both fine and imprisonment, who:

(a) Assumes the degree of "doctor of dental surgery," "doctor of dental science," or "doctor
of dental medicine" or appends the letters "DDS," or "DDSc" or "DMD" to his or her name
without having had the right to assume the title conferred upon him or her by diploma from a
recognized dental college or school legally empowered to confer the same.

(b) Assumes any title, or appends any letters to his or her name, with the intent to
represent falsely that he or she has received a dental degree or license.

(c) Engages in the practice of dentistry without causing to be displayed in a conspicuous
place in his or her office the name of each and every person employed there in the practice of
dentistry.

(d) Within 10 days after demand is made by the executive officer of the board, fails to
furnish to the board the name and address of all persons practicing or assisting in the
practice of dentistry in the office of the person, company, or association, at any time within
60 days prior to the demand, together with a sworn statement showing under and by what license
or authority this person, company, or association and any employees are or have been
practicing dentistry. This sworn statement shall not be used in any prosecution under this
section.

(e) Is under the influence of alcohol or a controlled substance while engaged in the
practice of dentistry in actual attendance on patients to an extent that impairs his or her
ability to conduct the practice of dentistry with safety to patients and the public.

Section 1700.5. Notwithstanding Section 1700, any person who holds a valid, unrevoked, and unsuspended certificate as a dentist under this chapter may append the letters "DDS" to his or her name, regardless of the degree conferred upon him or her by the dental college from which the licensee graduated.

Section 1701. Any person is for the first offense guilty of a
misdemeanor and shall be punishable by a fine of not less than two hundred dollars ($200) or
more than three thousand dollars ($3,000), or by imprisonment in a county jail for not to
exceed six months, or both, and for the second or a subsequent offense is guilty of a felony
and upon conviction thereof shall be punished by a fine of not less than two thousand dollars
($2,000) nor more than six thousand dollars ($6,000), or by imprisonment pursuant to
subdivision (h) of Section 1170 of the Penal Code, or by both such fine and imprisonment,
who:

(a) Sells or barters or offers to sell or barter any dental
degree or any license or transcript made or purporting to be made pursuant to the laws
regulating the license and registration of dentists.

(b) Purchases or procures by barter any such diploma, license
or transcript with intent that the same shall be used in evidence of the holder's
qualification to practice dentistry, or in fraud of the laws regulating such practice.

(c) With fraudulent intent, makes or attempts to make,
counterfeits or alters in a material regard any such diploma, certificate or
transcript.

(d) Uses, attempts or causes to be used, any such diploma,
certificate or transcript which has been purchased, fraudulently issued, counterfeited or
materially altered, either as a license to practice dentistry, or in order to procure
registration as a dentist.

(e) In an affidavit, required of an applicant for examination,
license or registration under this chapter, willfully makes a false statement in a material
regard.

(f) Practices dentistry or offers to practice dentistry as it
is defined in this chapter, either without a license, or when his license has been revoked or
suspended.

(g) Under any false, assumed or fictitious name, either as an
individual, firm, corporation or otherwise, or any name other than the name under which he is
licensed, practices, advertises or in any other manner indicates that he is practicing or will
practice dentistry, except such name as is specified in a valid permit issued pursuant to
Section 1701.5.

Section 1701.1. (a) Notwithstanding Sections 1700 and 1701, a person who willfully, under circumstances or conditions that cause or create risk of bodily harm, serious physical or mental illness, or death, practices or attempts to practice, or advertises or holds himself or herself out as practicing dentistry without having at the time of so doing a valid, unrevoked, and unsuspended certificate, license, registration, or permit as provided in this chapter, or without being authorized to perform that act pursuant to a certificate, license, registration, or permit obtained in accordance with some other provision of law, is guilty of a public offense, punishable by a fine not exceeding ten thousand dollars ($10,000), by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, by imprisonment in a county jail not exceeding one year, or by both the fine and either imprisonment.

(b) A person who conspires with or aids and abets another to commit any act described in
subdivision (a) is guilty of a public offense and subject to the punishment described in
subdivision (a).

(c) The remedy provided in this section shall not preclude any other remedy provided by
law.

LAWS GOVERNING THE PRESCRIPTION OF DRUGS

The California Dental Practice Act states that only doctors of
dentistry are permitted to prescribe drugs, including analgesics, sedatives, and antibiotics,
although prescription of oral conscious sedation to children younger than 13 years of age
requires a permit. Dental assistants and dental hygienists are not permitted to write
prescriptions [1]. There are many federal and
state laws and regulations pertaining to prescribing. It is the responsibility of each Drug
Enforcement Agency (DEA)-registered prescriber (or those exempted) to be familiar with and
maintain knowledge of all applicable laws and regulations. Pertinent citations of federal laws
governing the prescription of controlled substances are included in the DEA Practitioner's
Manual, available at http://www.deadiversion.usdoj.gov/pubs/manuals/pract. The California Uniform
Controlled Substances Act (part of the California Health and Safety Code) can be found at
http://www.leginfo.ca.gov/.html/hsc_table_of_contents.html. The Substances Act
begins at Section 11000, and information regarding prescriptions begins in Section
11150.

There must be careful consideration when prescribing to addicts or suspected addicts, particularly when patients are requesting specific drugs. The following section of the Act addresses the facilitation of abuse by prescribing practices.

Section 725. (a) Repeated acts of clearly excessive prescribing, furnishing, dispensing, or administering of drugs or treatment, repeated acts of clearly excessive use of diagnostic procedures, or repeated acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of the community of licensees is unprofessional conduct for a physician and surgeon, dentist, podiatrist, psychologist, physical therapist, chiropractor, optometrist, speech-language pathologist, or audiologist.

(b) Any person who engages in repeated acts of clearly excessive prescribing or
administering of drugs or treatment is guilty of a misdemeanor and shall be punished by a fine
of not less than one hundred dollars ($100) nor more than six hundred dollars ($600), or by
imprisonment for a term of not less than 60 days nor more than 180 days, or by both that fine
and imprisonment.

(c) A practitioner who has a medical basis for prescribing, furnishing, dispensing, or
administering dangerous drugs or prescription controlled substances shall not be subject to
disciplinary action or prosecution under this section.

REPORTING OF ABUSE AND NEGLECT

In accordance with California Penal Code Section 11165.7,
dentists, dental assistants, and dental hygienists are mandated reporters of child abuse and
neglect [3]. Reporting suspected abuse is not
only an ethical duty but is also a legal obligation.

CHILD ABUSE AND NEGLECT REPORTING LAW

Section 11164. (a) This article shall be known and may be cited as the Child Abuse and Neglect Reporting Act.

(b) The intent and purpose of this article is to protect children from abuse and neglect.
In any investigation of suspected child abuse or neglect, all persons participating in the
investigation of the case shall consider the needs of the child victim and shall do whatever
is necessary to prevent psychological harm to the child victim.

Section 11166. (a) Except as provided in Section 11166.05, a mandated reporter shall make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter shall make an initial report to the agency immediately or as soon as is practicably possible by telephone and the mandated reporter shall prepare and send, fax, or electronically transmit a written follow-up report thereof within 36 hours of receiving the information concerning the incident. The mandated reporter may include with the report any nonprivileged documentary evidence the mandated reporter possesses relating to the incident.

Section 11165.9. Reports of suspected child abuse or neglect shall be made by mandated reporters, or in the case of reports pursuant to Section 11166.05, may be made, to any police department or sheriff's department, not including a school district police or security department, county probation department, if designated by the county to receive mandated reports, or the county welfare department. Any of those agencies shall accept a report of suspected child abuse or neglect whether offered by a mandated reporter or another person, or referred by another agency, even if the agency to whom the report is being made lacks subject matter or geographical jurisdiction to investigate the reported case, unless the agency can immediately electronically transfer the call to an agency with proper jurisdiction. When an agency takes a report about a case of suspected child abuse or neglect in which that agency lacks jurisdiction, the agency shall immediately refer the case by telephone, fax, or electronic transmission to an agency with proper jurisdiction. Agencies that are required to receive reports of suspected child abuse or neglect may not refuse to accept a report of suspected child abuse or neglect from a mandated reporter or another person unless otherwise authorized pursuant to this section, and shall maintain a record of all reports received.

IDENTIFYING, DOCUMENTING, AND REPORTING ABUSE AND NEGLECT

Preventing serious morbidity and mortality involves
intervening at the first suspicion or indication of abuse and/or neglect. Dentists and
dental hygienists are often the healthcare professionals who have the most frequent
interactions with children and should be attentive to any signs of neglect and physical
abuse—as abusive injuries commonly involve the face, jaw, mouth, teeth, and tongue [4]. One study found that orofacial trauma was
concurrent with 49% of documented cases of child physical abuse [5]. Other studies show that craniofacial and
neck injuries occur in 50% to 65% of child abuse victims and that the lips are a site for
abusive injury in 54% of cases [6,7].

Clinical Signs of Abuse

The American Academy of Pediatrics (AAP) Committee on Child
Abuse and Neglect and the California Dental Association (CDA) have published useful
guidelines regarding the identification of the orofacial signs of abuse and particular
injuries of concern. According to these guidelines, possible signs of abuse include [6,7]:

Forced feeding injuries caused by eating utensils, bottles, hands, fingers, and other objects; scalding liquids; or caustic substances. These may be responsible for burns, contusions, or lacerations of the lips, tongue, buccal mucosa, gingival alveolar mucosa, frenum, or palate (soft and hard). Objects forced into the face/mouth may also cause facial bone and jaw fractures and avulsed, displaced, or fractured teeth.

Mouth gagging injuries resulting in bruises, lichenification, or scarring at the corners of the mouth

Strangulation injuries resulting in bruising, a hoarse or raspy voice, and difficulty breathing

During examination, excessive caries, gingivitis, and oral infections/diseases should be noted as possible signs of neglect. (Parents or caretakers with an ignorance of proper oral care, who have no perceived value of oral health, with limited access to health care or insurance, and/or geographic isolation should be differentiated from those with a willful disregard for the child's health [6].) Perioral and intraoral injuries and infections in various stages of healing, especially those that seem inappropriate for the child's developmental age, should be documented.

Although accidental injuries are common in pediatric patients, the history of trauma, including mechanism and timing, must be weighed against the injury features. Characteristics of the injury that do not seem to match the reported history should spur suspicion of abuse. The CDA's Dental Professionals Against Violence Reference Manual is a useful resource for dental professionals and includes the acronym RADAR to assist in the routine abuse screening of patients [7]:

Recognize signs and symptoms of abuse/neglect,
routinely screen

Ask direct, non-judgmental questions with
compassion

Document your findings

Assess patient safety

Review, refer, report

A parent or primary caretaker may be genuinely unaware of the abuse or injuries and may not be able to offer information relevant to the history. It is important not to make judgments of family members (either innocent or guilty), apportion blame, or attempt to personally undertake a criminal investigation. The scope of dental practice does not include these actions, and they may interfere with a law enforcement investigation. The AAP notes that the dental professional's role in a criminal investigation is to interpret medical information for nonmedical professionals in an understandable manner that accurately reflects the medical data [8]. Identify the medical problem, document the suspected abuse, treat the injuries, and offer honest, factual medical information to parents, families, law enforcement, and justice officials.

Reporting Abuse

As noted in the California Dental Practice Act, dental healthcare professionals have a legal and ethical responsibility to report suspected child abuse to the proper authorities, not to punish perpetrators of abuse but to protect the abuse victims. One author writes, "The dentist must view himself as a child advocate. Simply treating dental and facial injuries of abused children while ignoring the social needs of the child and family is unacceptable" [9].

Nonetheless, the decision of whether or not to report suspected abuse is ethically challenging. Although healthcare professionals are obligated to report suspected abuse, suspicion of abuse is somewhat of a judgment call and certain biases may influence the decision to report. It has been noted that well-intentioned professionals in all fields are swayed by both negative and positive social biases (e.g., sex, race, socioeconomic status, physical appearance, job status), and it is advisable to challenge personal biases and weigh only the facts of the case. A 2008 prospective, observational AAP study found that, "clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse" because of various biases and experiences [10]. However, patients who had an injury that was not a laceration, who had more than one family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who had a parental history of substance abuse, or who were unfamiliar to the clinician were more likely to be reported.

Professionally mandated reporters are protected from civil or criminal prosecution in consequence of a good-faith report of abuse, and no clinician in the aforementioned AAP study was sued for malpractice as a result of reporting abuse [7,10]. However, it is possible for dental professionals to be sued, and a state petition for up to $50,000 in recompensatory legal fees is available for dentists having to defend themselves in court [7]. On the other hand, civil or criminal penalties for willfully not reporting abuse or impeding a report when abuse has been found to have occurred include 6 months in jail and/or a fine of $1000 or, in cases of serious injury/death following a failure to report, 12 months in jail, and/or a fine of $5000.

ELDER AND DEPENDENT ADULT ABUSE AND NEGLECT

Abusive injuries to the mouth and oral cavity of elder or dependent adults are similar in type and causation to those sustained by pediatric patients, including trauma from forced feeding, object insertion, mouth gagging, and being slapped, hit, or strangled, but also include damage to and from prostheses. The number of new elder and dependent adult abuse cases is usually about 11,000 per month in California alone, with family members constituting two-thirds of perpetrators [11]. However, researchers estimate that for each incident of reported abuse there are at least five (and perhaps up to 14) unreported incidents [11,12]. Studies have shown that dental professionals are reluctant to report elder or dependent abuse/neglect and that they have a low index of suspicion of this category of abuse [13].

The national frequency of elder abuse is estimated at 2% to 10%, with a steady increase in reporting over the last few decades [14]. Contrary to popular belief, the overwhelming majority of abuse and neglect occurs in domestic, rather than institutional (e.g., residential care), settings [12]. Women are the victims of elder abuse two-thirds of the time.

Elder and dependent adults are also at risk for poor oral
health due to caretaker neglect. In fact, neglect is the one of the most common causes of
elder injury reporting (roughly 500,000 cases per year in the United States) [14]. These populations are also at a high risk
for self-neglect, accounting for more than 500,000 additional reported cases in the United
States per year. A 2010 study revealed that 40% of individuals 65 years of age or older
suffer from some form of neglect [15].

Elder and Dependent Adult Abuse Laws

Laws pertaining to mandatory elder and dependent adult abuse reporting are found in the California Welfare and Institutions Code Sections 15600 to 15632 [16].

Section 15600. (a) The Legislature recognizes that elders and dependent adults may be subjected to abuse, neglect, or abandonment and that this state has a responsibility to protect these persons.

(i) Therefore, it is the intent of the Legislature in enacting this chapter to provide
that adult protective services agencies, local long-term care ombudsman programs, and
local law enforcement agencies shall receive referrals or complaints from public or
private agencies, from any mandated reporter submitting reports pursuant to Section 15630,
or from any other source having reasonable cause to know that the welfare of an elder or
dependent adult is endangered, and shall take any actions considered necessary to protect
the elder or dependent adult and correct the situation and ensure the individual's
safety.

Section 15630. (a) Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter.

(b) (1) Any mandated reporter who, in his or her professional capacity, or within the
scope of his or her employment, has observed or has knowledge of an incident that
reasonably appears to be physical abuse, abandonment, abduction, isolation, financial
abuse, or neglect, or is told by an elder or dependent adult that he or she has
experienced behavior, including an act or omission, constituting physical abuse,
abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects
that abuse, shall report the known or suspected instance of abuse by telephone or through
a confidential Internet reporting tool, as authorized by Section 15658, immediately or as
soon as practicably possible. If reported by telephone, a written report shall be sent, or
an Internet report shall be made through the confidential Internet reporting tool
established in Section 15658, within two working days.

INTIMATE PARTNER VIOLENCE

Intimate partner violence is defined as violence directed at a "spouse, former spouse, cohabitant, former cohabitant, or person with whom the suspect has had a child or is having or has had a dating or engagement relationship" [7]. In the United States in 2011, severe physical violence by an intimate partner (including acts such as being hit with something hard, being kicked or beaten, or being burned on purpose) had been experienced by an estimated 22.3% of women and 14.0% of men during their lifetimes [17].

Dental professionals should be vigilant in recognizing signs of abuse among adolescent and adult patients. Facial injuries occur in 94% of intimate partner violence cases and are similar to those already discussed [18]. Again, dental visits may be a patient's only contact with healthcare professionals, making identification of abuse an important part of dental visits [7]. A history of intimidation, fear, isolation, and dependency is often present in victims of abuse, so it is especially important to determine the origin of orofacial injuries through the use of nonjudgmental questions. The CDA recommends the following line of indirect questioning for use with most age groups [7]:

"I am concerned that your symptoms/injuries may have been caused by someone hurting you."

"I don't know if this is (or has ever been) a problem for you, but many of the patients I see are dealing with abuse/abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I have started asking about it routinely."

"Did someone cause these injuries? Was it your parent/caretaker/partner/husband?"

"Are you in a relationship with (or do you live with) someone who physically hurts or threatens you?"

"Is it safe for you to go home?"

It is up to the practitioner's judgment which line of questioning to employ. Remember that the objectives are to advocate for and protect the patient.

When working cross-culturally, it is helpful to learn the colloquialisms used to describe abuse. For example, in some Latino cultures "disrespected me" refers to intimate partner violence [7]. If abuse is suspected and there is a cultural disconnect, consider the assistance of a knowledgeable co-worker, who may be able to act as a cultural broker.

CONCLUSION

Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. Dental professionals with a good knowledge of the Dental Practice Act and its effects on dental care will practice legally and safely.

26. California Department of Social Services. Adult Protective Services and County Block Grant Monthly Statistical Report. Available at http://www.cdss.ca.gov/research/PG345.htm. Last accessed January 19, 2016.

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